Annals for Hospitalists - November 2023
Authors: David A. Fried
Journal: Annals of Internal Medicine (2023)

Web ExclusivesNovember 2023Annals for Hospitalists - November 2023FREEDavid A. Fried, MDDavid A. Fried, MDFrom University of Michigan, Ann Arbor, Michigan (D.A.F.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWHO202311210 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Highlights of Recent Articles From Annals of Internal MedicineEffect of Complementary Interventions to Redesign Care on Teamwork and Quality for Hospitalized Medical Patients: A Pragmatic Controlled TrialAnn Intern Med. 2023;176:1456-1464. Published 31 October 2023. doi:10.7326/M23-0953This pragmatic controlled trial was done at 4 U.S. hospitals and evaluated the effect of the following unit-based interventions on teamwork climate (n = 155 health care professionals) and patient-level outcomes (n = 3773 patients): geographic physician teams, nurse–physician coleadership, performance reports, enhanced interprofessional rounds, and patient engagement activities. Each site included 2 general medicine units—an intervention unit and a control unit. After implementation, the teamwork climate score increased for nurses (median score increased from 80.0 [interquartile range, 70.0 to 89.0] to 88.0 [interquartile range, 77.0 to 91.0]; P = 0.022) but not for physicians. Regarding patient-level outcomes, after implementation there was no change in the number of patients with 1 or more adverse outcomes in the intervention units, and a difference-in-differences analysis was negative between the intervention and control units. In addition, length of stay, readmissions, and patient experience did not change after implementation.Key points for hospitalists include:The specific hospital unit–based interventions evaluated in this study led to an improved teamwork climate among nurses, but not physicians, and had no noticeable effect on the measured patient outcomes.This study is unique because it examined the implementation of a combination of interventions at multiple hospitals.Adverse events occurred at a lower frequency than anticipated (3.2% vs. estimate of 8.9%), lowering the power of the study to detect differences.Impact of Clinical Demands on the Educational Mission in Hospital Medicine at 17 Academic Medical Centers: A Qualitative AnalysisAnn Intern Med. 2023;176:1526-1535. Published 14 November 2023. doi:10.7326/M23-1497This qualitative study used semistructured interviews of hospitalist leaders from 17 academic centers to evaluate how increasing clinical growth has affected the educational mission. After analyzing the interviewee responses, the authors found 3 key themes:Key points for hospitalists include:First, academic medical centers have experienced a disproportionate growth in their clinical enterprises leading to decreased opportunities for traditional ward teaching time, research, and scholarship in general.Second, because the opportunities for preferred traditional teaching roles have diminished, academic hospital medicine groups have needed to change recruitment strategies (such as hiring purely clinical track hospitalists), develop deliberate ways of allocating the available teaching time, and provide innovative solutions to building clinician-educator careers (such as increasing nontraditional educational opportunities).Third, hospital medicine groups are working to reimagine the role of academic hospitalists by providing tailored career pathways, including education, research, quality improvement, utilization management, health information technology, and health care leadership.Hospitalized While Incarcerated: Incarceration-Specific Care PracticesAnn Intern Med. 2023;176:1540–1541. Published 24 October 2023. doi:10.7326/M23-1873In this Ideas and Opinions piece, the authors describe several core ways in which health care delivery differs for incarcerated patients when they are admitted to noncarceral hospitals and how these differences likely exacerbate health disparities in this population.Key points for hospitalists include:Decreased provider engagement: reduced time with health care professionals due to physical barriers and the presence of correctional officers.Privacy violations: Federal law mandates that health care information disclosure to individuals or institutions other than the patient should be the minimum necessary for proper care and can only be made after a full clinical evaluation without the presence of correctional officers (when deemed safe). Despite this, prior data show that 65% of physicians and 21% of nurses do not ask officers to leave the room during examination.Impaired patient autonomy: Incarcerated patients have the right to involve friends and family in making medical decisions, but data show that health care providers lack knowledge about this topic, and institutions often prohibit communication between incarcerated patients and the outside world.Fewer medical interventions: Data (albeit limited) show that incarcerated patients receive fewer subspecialty consultations and evaluations by physical therapy, dietitians, and social work. Health care providers are also hesitant to prescribe controlled substances and medications for substance use disorders due to fear of diversion.Continuous shackled restraint: Despite hospital policies allowing for removal of restraints, incarcerated patients often remain shackled in metal cuffs throughout the duration of their hospitalization, which violates personal liberties and can increase the risk for medical complications.The Latest Highlights From Journal ClubHow does dual antiplatelet therapy (DAPT) compare with intravenous (IV) thrombolysis in treating minor ischemic strokes?In minor, nondisabling, acute ischemic stroke, DAPT was noninferior to IV alteplase for excellent functional outcome at 90 dAnn Intern Med. 2023;176:JC110. doi:10.7326/J23-0072This randomized controlled noninferiority trial (n = 760) of patients with nondisabling ischemic stroke (National Institutes of Health Stroke Scale score ≤5) found that treatment with clopidogrel and aspirin for 14 days followed by guideline-based antiplatelet therapy was noninferior to IV alteplase followed by guideline-based antiplatelet therapy in terms of achieving excellent clinical outcomes at 90 days.Does tirofiban, a glycoprotein IIb/IIIa inhibitor improve ischemic stroke outcomes compared with aspirin?In ischemic stroke without large or medium vessel occlusion, tirofiban increased likelihood of an excellent outcomeAnn Intern Med. 2023;176:JC111. doi:10.7326/J23-0074This randomized controlled trial (n = 1177) found that patients with nonembolic, small-vessel acute ischemic stroke (National Institutes of Health Stroke Scale score ≥5) who are not candidates for thrombolytic therapy (or who had worsened symptoms after thrombolytics) had improved rates of excellent clinical outcomes at 90 days when treated with IV tirofiban followed by aspirin compared with those treated with aspirin alone (number needed to treat, 18 [95% CI, 9 to 113]), with slightly higher rates of symptomatic intracerebral bleeding (1% vs. 0% at 48 hours).Do patients with intermediate- or high-risk pulmonary embolism (PE) benefit from catheter-directed thrombolysis?In intermediate- or high-risk PE, catheter-directed thrombolysis is linked to reduced mortality vs. systemic thrombolysis or anticoagulationAnn Intern Med. 2023;176:JC118. doi:10.7326/J23-0076This systematic review and meta-analysis of 44 studies (n = 20 006) found that patients with intermediate- or high-risk PE treated with catheter-directed thrombolysis had lower odds of in-hospital death compared with those treated with systemic thrombolysis (odds ratio, 0.43 [CI, 0.32 to 0.57]) or anticoagulation alone (odds ratio, 0.36 [CI, 0.25 to 0.52]).Sign up here to have Annals for Hospitalists delivered to your inbox each month. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: David A. Fried, MDAffiliations: From University of Michigan, Ann Arbor, Michigan (D.A.F.)Disclosures:The author has reported no disclosures of interest. Forms can be viewed at https://rmed.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M23-1807. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Current IssueNovember 2023Volume 176, Issue 11 ePublished: 21 November 2023 Issue Published: November 2023 Copyright & PermissionsCopyright © 2023 by American College of Physicians. All Rights Reserved.Loading ...